Introduction

In most prevalence studies of major depressive disorder, roughly twice as many women than men are represented among adults with MDD. This finding is so well established as to appear nearly axiomatic, and, as a result, depression is heavily conceptualized as a female disease.

“Regarding the gender disparity in the prevalence of depression, many potential explanations in the literature focus on women’s roles in society and hormonal experiences,” says Dr. Lisa Martin. “Coming at this subject from a feminist perspective, I began to think that maybe we were asking the wrong questions in our research. So instead of asking, ‘Why are women diagnosed with depression more frequently than men?’ I wanted to approach the subject instead from the standpoint of, ‘Why are men diagnosed with depression less frequently than women?’”

Over the past decade, a small but growing notion appeared in the literature suggesting that men with depression may actually present more frequently than women but with some alternative symptoms that women with depression are less likely to endorse. These symptoms, which are mainly externalizing, are known as “alternative male-type symptoms,” and include anger attacks, irritability, substance use, and impulsivity.1

Methodology

Dr. Martin and colleagues conducted the first nationally representative epidemiological study on the prevalence of MDD among men when factoring in male-type symptoms of depression.2 They created two new depression measures: the Male Symptoms Scale (MSS), which measures male-type symptoms only, and the Gender Inclusive Depression Scale (GIDS), which combines male-type symptoms with traditional depression criteria. These scales were applied secondarily to Part II of the National Comorbidity Survey Replication (n=5,692), composed of respondents from Part I of that study who met lifetime criteria for any primary psychiatric disorder.

Findings

In addition to traditional diagnostic criteria for depression, men were significantly more likely than women to endorse symptoms of anger attacks and aggression, substance use, and risk-taking behaviors. In contrast, women endorsed stress, irritability, sleep disturbance, and loss of interest at significantly greater rates than men.

“It’s not that all men endorsed these alternative male-type symptoms,” says Dr. Martin. “Rather, by including those alternative symptoms in the diagnostic criteria, it may be possible to identify cases of depression in men which the traditional criteria alone would identify as sub-threshold depression. Among both women and men, however, the traditional criterion of depressed mood or sadness was the most frequently endorsed criterion. This suggests that the traditional diagnostic criteria for depression describe some cases of depression in men accurately, although they may be insufficient for capturing the true prevalence of depression among men in the general population.”

Implications & Conclusions

“There is a fine line between questioning whether the current diagnostic criteria are missing something critical vs opening the door so wide that a sizable part of the general population fit the criteria for depression,” says Dr. Martin. “I think part of the key lies in the accounts written by clinicians who have observed the varying presentations of depression in men. Those clinicians noted several things. One, that men were not good at recognizing a need for, and seeking, treatment. External “threats,” such as changes in job functioning or strained relationships with a partner often led them to seek treatment. Second, the clinicians noted how the traditional criteria alone would not endorse a diagnosis of MDD, although clinical experience and patient self-report would reveal otherwise to be the case.

“It may not cross the radar of many clinicians that some of their male patients may actually be experiencing depression,” continues Dr. Martin. “It is important to place emphasis on screening men for depression, especially as we continue to rely upon general practitioners to remain vigilant for symptoms of depression in their patients.”

Disclosure: Dr. Martin reports no affiliations with, or financial interests in, any organization that may pose a conflict of interest.